Finkelstein Jonathan A, Huang Susan S, Kleinman Ken, Rifas-Shiman Sheryl L, Stille Christopher J, Daniel James, Schiff Nancy, Steingard Ron, Soumerai Stephen B, Ross-Degnan Dennis, Goldmann Donald, Platt Richard
Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Ave, Sixth Floor; Boston, MA 02215, USA.
Pediatrics. 2008 Jan;121(1):e15-23. doi: 10.1542/peds.2007-0819.
Reducing unnecessary antibiotic use, particularly among children, continues to be a public health priority. Previous intervention studies have been limited by size or design and have shown mixed results. The objective of this study was to determine the impact of a multifaceted, community-wide intervention on overall antibiotic use for young children and on use of broad-spectrum agents. In addition, we sought to compare the intervention's impact on commercially and Medicaid-insured children.
We conducted a controlled, community-level, cluster-randomized trial in 16 nonoverlapping Massachusetts communities, studied from 1998 to 2003. During 3 years, we implemented a physician behavior-change strategy that included guideline dissemination, small-group education, frequent updates and educational materials, and prescribing feedback. Parents received educational materials by mail and in primary care practices, pharmacies, and child care settings. Using health-plan data, we measured changes in antibiotics dispensed per person-year of observation among children who were aged 3 to <72 months, resided in study communities, and were insured by a participating commercial health plan or Medicaid.
The data include 223,135 person-years of observation. Antibiotic-use rates at baseline were 2.8, 1.7, and 1.4 antibiotics per person-year among those aged 3 to <24, 24 to <48, and 48 to <72 months, respectively. We observed a substantial downward trend in antibiotic prescribing, even in the absence of intervention. The intervention had no additional effect among children aged 3 to <24 months but was responsible for a 4.2% decrease among those aged 24 to <48 months and a 6.7% decrease among those aged 48 to <72 months. The intervention effect was greater among Medicaid-insured children and for broad-spectrum agents.
A sustained, multifaceted, community-level intervention was only modestly successful at decreasing overall antibiotic use beyond substantial secular trends. The more robust impact among Medicaid-insured children and for specific medication classes provides an argument for specific targeting of resources for patient and physician behavior change.
减少不必要的抗生素使用，尤其是在儿童中，仍然是公共卫生的重点。以往的干预研究受到规模或设计的限制，结果不一。本研究的目的是确定一项多方面的、全社区范围的干预措施对幼儿总体抗生素使用以及广谱抗生素使用的影响。此外，我们试图比较该干预措施对商业保险儿童和医疗补助保险儿童的影响。
1998年至2003年，我们在马萨诸塞州16个不重叠的社区进行了一项对照的、社区层面的整群随机试验。在3年时间里，我们实施了一项医生行为改变策略，包括指南传播、小组教育、频繁更新和教育材料以及处方反馈。家长通过邮件以及在初级保健机构、药房和儿童保育场所收到教育材料。利用健康计划数据，我们测量了年龄在3岁至<72个月、居住在研究社区且由参与的商业健康计划或医疗补助保险的儿童中，每人每年观察期内抗生素配药的变化。
数据包括223,135人年的观察期。在3岁至<24个月、24岁至<48个月和48岁至<72个月的儿童中，基线时抗生素使用率分别为每人每年2.8、1.7和1.4种抗生素。即使在没有干预的情况下，我们也观察到抗生素处方有大幅下降趋势。该干预措施对3岁至<24个月的儿童没有额外影响，但导致24岁至<48个月的儿童抗生素使用量下降了4.2%，48岁至<72个月的儿童抗生素使用量下降了6.7%。该干预措施对医疗补助保险儿童和广谱抗生素的影响更大。
一项持续的、多方面的、社区层面的干预措施在减少超出长期趋势的总体抗生素使用方面仅取得了适度成功。在医疗补助保险儿童和特定药物类别中影响更为显著，这为针对患者和医生行为改变的资源进行特定目标定位提供了依据。
